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San J< *jin County Envii-onmental Health opartment <br /> GREEN FORM <br /> DATE �uY1e_ 9, ZCX��- MASTER FILE RECORD INFORMATION IAMFRrr <br /> gtenrneorec FOR FHn acrnxry OWNERID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOHQNG PROPERTY OWNER INFORMA 770M � CHEOEIF OWNER CHRRENnrovnuw vEHD <br /> PROPERTY OWNER NAME �^ Al l e-y1 PHONE 00(3- 4-17 6— I-7 q ` <br /> .L,, U First I MI Last <br /> Business NAME S t V�e. al lJt r 1��g Soc SEc/Tm ID# N/A <br /> OWner Home Address DRIVER'SLICENSE# N/A <br /> city STATE ZIP <br /> owner Mailing Address to a y w. Qdo1y�hex>� fir. <br /> Mailing Address City K-1-p)"'1 "a" CA rap 95007 <br /> Tvor nF nwN <br /> CoRPORAnoN ElDorvm^uAt.❑ PARTNERSHIP❑ FEO AGENCY 11OTHER❑ <br /> CAO IVO , 5—D(J ^� O`7 FACILITY FILE <br /> FAaLITY ID# CROs REF ID At ACCOUNT.ID# IN9# <br /> ComPLETE THEFoLLowiNG BUSINESS I FACILITY I SrrE INFORMATrom <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No R1 <br /> Is this an DUSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACn.ITY/SITENAME Former Unocal -W5098 <br /> vre AopaaesS ,&o(Q T�- Ci-Pie_ . Avenue- Sucre# BUssNess PHONE <br /> CITY s+3c-K+On STATE C)A 21P 95ao7 <br /> Bosom oF.SOPecyrsoit DisnucT LOUT[DN CODE' KEYS M2. <br /> Mailing Address ffDLFFERENThom FaolityAddress Attention:of Care Of(optional) <br /> *7 T 14 FOS' �d. {�r©,�Ue1X I(xD� Bob t �e KiYISCv <br /> Mailing Address City Sar\ Leis ©b1S{7o STATE CA ZIP 93�+OCo <br /> SIC CODE APIC# COMMENT:: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party isdifferent from Property Owner or Facility Operator identJ'fied above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> ENSi2 Ben He-nin bur <br /> Mailing Address (0q1) old PI ac.eru� Ile cemd a,ife- al0 PHONe ql(C 3(cQ 7100 <br /> CITY eoc -wrien+o sTAn" CA '�'° gSBQ-7 <br /> Acc"WT—,looRrss'for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> nnttNr.ANn r omp unrr Aruvnwi Ew.mv,NT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMITFaas, <br /> PENALTIES,£HF'oRcEME,vr CHARGES and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACCOEWTADDxRce for this site. I also certify that all <br /> information provided on this application is true and correct and that all regulated activities will be performed in accordance with all applicable SAN JOAquiN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same is <br /> provided to me or my representative. A D/ <br /> PLEASE PRINT //'- F's' <br /> APPLICANT NAME �epLffl,4,�iUYq SIGNATURE I <br /> TITLEN/I������ /f� DRIVER'S LICENSE# FILE UUrT <br /> a61L r!f E✓LJ fPHOTocowREoumED) <br /> Approveal BY Date Accounting Office Processing Completed BY Data <br /> 29-02007 Andl?5 ?nna <br />